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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
WIC Participant
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Other-App.E.1_Eng.Screening_Enrollment.Participant.Interview.
App E 1_Eng Screening_Enrollment Participant Interview (revised).docx
Yes
Yes
Fillable Fileable
Other-App.E.2_Span.Screening_Enrollment.Participant.Interview
App E 2_Span Screening Enrollment Participant Interview (revised).docx
Yes
Yes
Fillable Fileable
Other-App.F.1_Eng.Prenatal Enrollment Package.Letter
App.F.1_Eng.Prenatal Enrollment Package.Letter.docx
No
Paper Only
Other-App.F.2_Span.Prenatal Enrollment Package.Letter
App.F.2_Span Prenatal Enrollment Package.Letter.docx
No
Paper Only
Other-App.G 1_Eng Postnatal Enrollment Package Letter
App.G 1_Eng Postnatal Enrollment Package Letter.V2.docx
No
Paper Only
Other-App.G 2_Span Postnatal Enrollment Package Letter
App.G 2_Span Postnatal Enrollment Package Letter.V2.docx
No
Paper Only
Other-App.I.1_Eng.Prental Participant Interview
App.I.1_Eng.Prental Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.I.2_Span.Prenatal Participant Interview
App.I.2_Span.Prenatal Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.J.1_Eng.1 Month Participant Interview
App.J.1_Eng.1 Month Participant Interview (revised).docx
Yes
Yes
Fillable Fileable
Other-App.J.2_Span.1 Month Participant Interview
App.J.2_Span.1 Month Participant Interview (revised).docx
Yes
Yes
Fillable Fileable
Other-App.K.1_Eng.3 Month Participant Interview
App.K.1_Eng.3 Month Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.K.2_Span.3 Month Participant Interview
App.K.2_Span.3 Month Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.L.1_Eng.5 Month Participant Interview
App.L.1_Eng.5 Month Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.L.2_Span.5 Month Participant Interview
App.L.2_Span.5 Month Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.M.1_Eng.7 Month Participant Interview
App.M.1_Eng.7 Month Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.M.2_Span.7 Month Participant Interview
App.M.2_Span.7 Month Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.N.1_Eng.9 Month Participant Interview
App.N.1_Eng.9 Month Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.N.2_Span.9 Month Participant Interview
App.N.2_Span.9 Month Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.O.1_Eng.11 Month Participant Interview
App.O.1_Eng.11 Month Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.O.2_Span.11 Month Participant Interview
App.O.2_Span.11 Month Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.P.1_Eng.13 Month Participant Interview
App.P.1_Eng.13 Month Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.P.2_Span.13 Month Participant Interview
App.P.2_Span.13 Month Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.Q.1_Eng.15 Month Participant Interview
App.Q.1_Eng.15 Month Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.Q.2_Span.15 Month Participant Interview
App.Q.2_Span.15 Month Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.R.1_Eng.18 Month Participant Interview
App.R.1_Eng.18 Month Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.R.2_Span.18 Month Participant Interview
App.R.2_Span.18 Month Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.S.1_Eng.24 Month Participant Interview
App.S.1_Eng.24 Month Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.S.2_Span.24 Month Participant Interview
App.S.2_Span.24 Month Participant Interview.docx
Yes
Yes
Fillable Fileable
Other-App.T.1_Eng.Baseline module.Participant.Interview
App.T.1_Eng.Baseline module.Participant.Interview.docx
Yes
Yes
Fillable Fileable
Other-App.T.2_Span.Baseline module.Participant.Interview
App.T.2_Span.Baseline module.Participant.Interview.docx
Yes
Yes
Fillable Fileable
Other-App.U.1_Eng.New Caregiver module.Participant.Interview
App.U.1_Eng.New Caregiver module.Participant.Interview.docx
Yes
Yes
Fillable Fileable
Other-App.U.2_Span.New Caregiver module.Participant.Interview
App.U.2_Span.New Caregiver module.Participant.Interview.docx
Yes
Yes
Fillable Fileable
Other-App.V.1 Eng Automated Multiple Pass Method 24HR.Module.Screenshots (revised)
App.V.1 Eng Automated Multiple Pass Method 24HR.Module.Screenshots (revised).pdf
Yes
Yes
Fillable Fileable
Other-App.DD.1_Eng.HomeHealthcareAgency.LengthWeight.Form
App.DD.1_Eng.HomeHealthcareAgency.LengthWeight.Form.docx
No
Paper Only
Other-App.DD.2_Span.HomeHealthcareAgency.LengthWeight.Form
App.DD.2_Span.HomeHealthcareAgency.LengthWeight.Form.V2.docx
No
Paper Only
Other-App.EE.1_Eng.Home Health Visit Script.LengthWeight
App.EE.1_Eng.Home Health Visit Script.LengthWeight.docx
No
Paper Only
Other-App.EE.2_Span.Home Health Visit Script.LengthWeight
App.EE.2_Span.Home Health Visit Script.LengthWeight.docx
No
Paper Only
Other-App V 2_Span Automated Multiple Pass Method 24HR Module Screenshots
App V 2_Span Automated Multiple Pass Method 24HR Module Screenshots.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Income Security
Subfunction:
Food and Nutrition Assistance
Privacy Act System of Records
Title:
Privacy Act of 1974
FR Citation:
5 FR 552
Number of Respondents:
4,468
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
99 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
18,667
0
18,667
0
0
0
Annual IC Time Burden (Hours)
4,426
0
4,426
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
App.A.1_Eng.WIC Poster
App.A.1_Eng.WIC Poster-v2.pdf
12/18/2012
App.A.2_Span.WIC Poster
App.A.2_Span.WIC Poster-V2.pdf
12/18/2012
App.B.1_Eng.Participant Flyer
App.B.1_Eng.Participant Flyer.docx
12/18/2012
App.B.2_Span.Participant Flyer
App.B.2_Span.Participant Flyer.docx
12/18/2012
App.H 1_Eng Post Birth HIPAA Letter
App.H 1_Eng Post Birth HIPAA Letter.V2.docx
12/18/2012
App.H 2_Span Post Birth HIPAA Letter
App.H 2_Span Post Birth HIPAA Letter.V2.docx
12/18/2012
App.Y.1_Eng_Core Participant Informed Consent
App.Y.1_Eng_Core Participant Informed Consent Amended Privacy (23May13).docx
05/23/2013
App.Y.2_Span_Core Participant Informed Consent
App.Y.2_Span_Core Participant Informed Consent Amended Privacy (23May13).docx
05/23/2013
App.Z.1_Eng_Supplemental Participant Consent
App.Z.1_Eng_Supplemental Participant Consent Amended Privacy (23May13)docx.docx
05/23/2013
App.Z.2_Span_Supplemental Participant Consent
App.Z.2_Span_Supplemental Participant Consent Amended Privacy(23May13).docx
05/23/2013
App.NN.1_Eng.Participant Reminder Scripts
App.NN.1_Eng.Participant Reminder Scripts.docx
12/18/2012
App.NN.2_Span.Participant Reminder Scripts
App.NN.2_Span.Participant Reminder Scripts.docx
12/18/2012
App.OO.1_Eng.Thankyou Letter
App.OO.1_Eng.Thankyou Letter.docx
12/18/2012
App.OO.2_Span.Thankyou Letter
App.OO.2_Span.Thankyou Letter.docx
12/18/2012
App.TT.Confidentiality & Nondisclosure Agreement
App.TT.Confidentiality & Nondisclosure Agreement.docx
12/18/2012
App.W.1_Eng 13 Month FoodModelBooklet.Letter
App.W.1_Eng 13 Month FoodModelBooklet.Letter.docx
12/19/2012
App.W.2_Span 13 Month FoodModelBooklet.Letter
App.W.2_Span 13 Month FoodModelBooklet.Letter.docx
12/19/2012
App.X.1_Eng Note sheet for AMPM.docx
App.X.1_Eng Note sheet for AMPM.docx
12/19/2012
App.X.2_Span Note sheet for AMPM
App.X.2_Span Note sheet for AMPM.docx
12/19/2012
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.